Autumn Woods Residential Health
Inspection history, citations, penalties and survey trends for this long-term care facility in Warren, Michigan.
- Location
- 29800 Hoover Rd, Warren, Michigan 48093
- CMS Provider Number
- 235427
- Inspections on file
- 39
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 27
Citation history
Health deficiencies cited at Autumn Woods Residential Health during CMS and state inspections, most recent first.
A hospice resident with CREST Syndrome Scleroderma and Rheumatoid Arthritis, who was cognitively intact, reported waking in severe morning pain and stated they wanted to be awakened for nighttime pain medication. Review of the care plan and orders showed scheduled morphine every four hours plus PRN dosing for breakthrough pain, but the MAR documented multiple missed midnight doses, with nursing staff recording that the medication was not given because the resident was sleeping. The UM and DON confirmed the doses were not administered despite orders and policies requiring pain management consistent with the resident’s care plan and expressed preferences.
A resident with Alzheimer’s dementia, admitted from a hospital and unable to complete a BIMs assessment, was identified by nursing staff as exit seeking during the first night but no specific elopement-prevention interventions were implemented. The resident repeatedly left their room overnight and required redirection, and the oncoming nurse verbally told CNAs to keep an eye on the resident. The next morning, while staff were passing breakfast trays and an LPN was doing a med pass near the smoker’s exit, the resident sat near the smoking area doors and then left the building by following a smoker through an unlocked, non-alarmed interior door routinely used for independent smoking. The resident walked off the premises and was later located at a nearby medical clinic and returned, with staff and internal review concluding that the resident had been assessed as an elopement risk but was not provided with appropriate interventions to prevent leaving the facility.
Several residents with severe cognitive impairment and total dependence on staff were repeatedly observed without accessible call lights, as devices were found on the floor, out of reach, or improperly placed. This occurred despite facility policy requiring call lights to be accessible and accommodations to be made for individual needs.
A resident with moderate cognitive impairment and multiple medical conditions repeatedly requested a room change due to dissatisfaction with their environment, lack of access to personal belongings, and frequent intrusions by other residents. Despite these requests and staff acknowledgment of an overstimulating environment, the facility did not address the resident's preferences or provide a room change policy, and no documented behaviors justified the resident's placement on a locked unit.
A resident with severe cognitive impairment and multiple comorbidities was discharged with unexplained bruising in various stages of healing, despite initial assessments showing no skin issues. Staff failed to thoroughly assess and document these injuries, and the facility could not determine the cause of most bruises. The required daily skin checks and reporting procedures were not followed, leading to a deficiency in protecting the resident from potential abuse or neglect.
A resident with a history of falls and requiring assistance with mobility was repeatedly observed without the prescribed fall mat next to the bed, as outlined in the care plan. Despite the care plan intervention, the fall mat was not in place during multiple observations, and staff could not account for its absence. Incident reports and the facility's fall policy were not provided during the survey.
A resident's room was found with stained linens, a sticky floor, soiled baseboards, and feces on the toilet seat, despite facility procedures requiring daily cleaning and disinfection. The DON confirmed the room required cleaning, and the resident had severe cognitive impairment but was independent in mobility.
A resident's privacy was compromised due to improperly placed cameras in their room, which faced the entry door and allowed monitoring by the resident's mother. The cameras' positioning potentially infringed on the privacy of others in the hallway. The resident had severe cognitive impairment and was non-verbal, requiring full assistance from staff. Despite being informed of the privacy concerns, the resident's mother insisted on her right to place the cameras as she wished.
A resident with cognitive impairment and mobility issues was verbally and physically abused by an LPN, who yelled profanities and lifted a couch to force the resident off, causing them to fall. The incident was witnessed by staff and reported to the Assistant Director of Nursing. The facility's abuse policy was violated as residents are entitled to be free from all forms of abuse.
A resident was subjected to verbal and physical abuse by an LPN, who yelled profanities and lifted the couch the resident was lying on, causing them to fall. The incident, witnessed by a nurse and a CNA, was not reported to the SA until two days later, constituting a delay in reporting abuse allegations.
The facility failed to maintain proper sanitation and food safety standards, as observed with ineffective sanitizer buckets and improperly dried dishware in the kitchen. Additionally, resident refrigerators contained undated and expired food items, violating the facility's food safety policies.
The facility failed to provide adequate personal care for three residents, resulting in deficiencies in activities of daily living (ADLs). A resident with Parkinsonism did not receive scheduled showers, another with hemiplegia was not shaved during bed baths, and a third resident had excessively long toenails. Staff cited equipment shortages and scheduling issues, but the care plans and facility policies were not followed.
The facility failed to document and date PICC line dressings for two residents. One resident had a gauze dressing without a date or transparent cover, and the insertion site was not visible. The LPN and Unit Manager acknowledged the oversight. The second resident's transparent dressing was undated, and records lacked documentation of dressing changes. The DON confirmed the requirement for transparent, dated dressings and regular assessments.
A resident fell from a mechanical lift due to a ripped sling, with only one CNA present, contrary to policy requiring two staff. Additionally, a resident was observed using a vape pen in their room, violating the facility's smoking policy. These deficiencies highlight lapses in policy enforcement regarding mechanical lift use and smoking materials management.
The facility failed to securely store medications for four residents. One resident had a pill on their overbed table, another had a capsule on their window sill, a third had an inhaler on their table, and a fourth had a bag of pills they were not taking. The facility's policy requires medications to be taken with a nurse present and refused medications to be removed.
A resident with a recent above-knee amputation reported that their bed's height adjustment was non-functional, making a loud grinding noise. Despite informing multiple staff members, including maintenance and nursing staff, the issue was not addressed. Interviews revealed that staff were aware of the problem but did not report it. The Maintenance Director was unaware of the issue due to the absence of work orders, and the facility lacked a policy for reporting malfunctioning equipment.
Failure to Administer Scheduled Morphine for Hospice Resident’s Nighttime Pain
Penalty
Summary
Surveyors identified a failure to provide ordered pain management when nursing staff did not administer scheduled morphine doses to a hospice resident as prescribed. The resident, admitted with CREST Syndrome Scleroderma and Rheumatoid Arthritis and assessed as cognitively intact, reported waking up in severe pain in the mornings and believed they were not receiving their nighttime pain medication. The resident stated they wanted to be awakened for nighttime medication, even if asleep, so that their pain would not become severe. The resident’s care plan under hospice services included administering medications as ordered, observing for effectiveness, evaluating for signs and symptoms of pain, and providing care based on the resident’s end-of-life comfort preferences. Record review showed physician orders for morphine 100 mg/5 ml, 2 ml every four hours, and an additional PRN order for 2 ml every two hours for breakthrough pain. The MAR for March documented that seven scheduled midnight doses of morphine were not administered on multiple dates, with RN documentation indicating the medication was withheld because the resident was sleeping. The Unit Manager confirmed, based on the electronic record and narcotic sign-out sheets, that these doses were not given and stated the medication should have been administered unless the resident requested not to be awakened. The DON also stated that medications should be given as ordered. Facility policies on Pain Management and Hospice required that pain management be provided consistent with professional standards, the care plan, and resident goals and preferences, including directives for managing pain and uncomfortable symptoms.
Failure to Implement Elopement Interventions for Newly Admitted Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement interventions to monitor and prevent elopement for a newly admitted resident with Alzheimer’s dementia who had been identified as an elopement risk. The resident was admitted from a hospital with diagnoses including Alzheimer’s and dementia, was unable to complete a BIMs assessment, and did not recognize their own name on nursing assessment. During the night shift, the resident repeatedly left their room, required redirection, and was described by the nurse as exit seeking. The nurse reported this exit-seeking behavior to the oncoming nurse and indicated the resident might need transfer to a secured unit, and the oncoming nurse was heard telling CNAs they needed to keep an eye on the resident. Despite this, no specific elopement-prevention intervention was put in place prior to the incident. On the morning of the elopement, the resident was observed on video sitting in a hallway chair and then moving to a dayroom sofa near the smoker’s exit doors while staff, including a nurse with a medication cart and CNAs passing breakfast trays, were present in the area. A CNA last saw the resident around the time breakfast trays were finished, then went to give another resident a 15–20 minute shower. Within approximately 45 minutes, the resident was no longer on the sofa and could not be located by staff. The CNA who had last seen the resident reported they had not received any direct report from night-shift CNAs about the resident’s exit-seeking behavior and initially thought the resident was a visitor when first observed sitting in the hallway. The resident exited the building through the smoker’s patio area, which was routinely unlocked during the day for independent smokers and, at the time of the incident, did not have an alarm on the interior set of doors. Staff interviews and a resident smoker confirmed that the interior door alarms were new and had not been in place or activated when smokers went out during the day prior to the elopement. Video review showed the resident walking down the sidewalk from the employee entrance toward the front of the building, and the facility later learned the resident had followed another resident who went out to smoke. The resident was found at a nearby medical clinic and returned to the facility, where they were noted to be confused by basic questions. The root cause identified by the facility was that the resident had scored as a risk for elopement on admission, but staff did not implement an intervention to prevent the resident from leaving the facility.
Failure to Ensure Call Light Accessibility for Dependent Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for four residents who were reviewed for care needs. Multiple observations over several days showed that these residents, all of whom had severely impaired cognition and were totally dependent on staff for activities of daily living, did not have access to their call lights while in bed. Specifically, call lights were found on the floor, looped over the call box or vent cart, or hanging below the bed frame, making them inaccessible to the residents. The residents involved had significant medical conditions, including renal failure, diabetes, malnutrition, respiratory failure, and stroke. Facility policy required that call lights be accessible at each resident's bedside and that special accommodations be provided as needed, but these requirements were not met for the residents observed. The deficiency was identified through direct observation, interviews, and record review.
Failure to Honor Resident Room Change Preference and Support Self-Determination
Penalty
Summary
The facility failed to honor a resident's preference for a room change, as well as other expressed choices, for one resident with moderate cognitive impairment and diagnoses including diabetes, hypertension, and dementia. The resident reported dissatisfaction with their care, specifically noting lack of access to their clothes due to a locked closet, not being allowed to leave the locked unit or go outside for an extended period, and frequent intrusions by other residents into their room. The resident stated that requests for a room change were made to both the unit manager and their guardian, but these requests were not addressed. Staff interviews confirmed that the environment was overstimulating for the resident, affecting their participation in meals and activities, and that staff availability limited the resident's ability to leave the unit for activities such as visiting the vending machine. Observations included another resident entering the affected resident's room and using their belongings, which the resident indicated was a recurring issue. Review of the medical record showed no documented behaviors that would necessitate placement on a locked unit, and the director of nursing confirmed there was no specific criteria for such placement. The resident's care plan and progress notes did not document behaviors justifying the current room assignment. Additionally, a request for the facility's room change policy was made but no policy was provided by the end of the survey.
Failure to Assess and Document Unexplained Bruising
Penalty
Summary
A resident admitted for a 7-day respite stay, with diagnoses including Alzheimer's Disease, severe protein-calorie malnutrition, and diabetes, was found to have multiple bruises of various stages of healing on discharge. Initial nursing and nurse practitioner assessments documented no skin integrity issues or visible rashes upon admission. The resident, who was severely cognitively impaired and required significant assistance with activities of daily living, was later observed by a CNA to have redness on the right arm on the day of discharge, which was reported to a nurse, though the specific nurse was not recalled. Documentation submitted to the State Agency included photos of bruises on the resident's neck, left shoulder, hand, chest, and shin, with some bruises appearing to be more advanced in healing than others. The facility's internal investigation could not substantiate the causes of all the bruises except for the hand, and the DON acknowledged that staff should have noticed the bruising during care. The facility's wound care policy required CNAs to check residents' skin daily and report any new findings to the charge nurse or unit management for immediate intervention, but this process was not followed, resulting in the failure to thoroughly assess and document the resident's skin bruising and injury of unknown origin.
Failure to Implement Fall Prevention Care Plan Intervention
Penalty
Summary
The facility failed to implement a fall care plan intervention for one resident who had a history of falls and required assistance with bed mobility and transfers. The resident, who had diagnoses of cerebral infarction and bipolar disorder and demonstrated intact cognition, was observed multiple times without the prescribed fall mat on the left side of the bed, despite the care plan specifying this intervention. The resident reported using a cane for mobility and acknowledged having experienced falls in the facility. During the survey, incident and accident reports for the resident were requested but not provided. Repeated observations confirmed the absence of the fall mat, and the unit manager was unable to explain why the intervention was not in place, suggesting maintenance may have moved it. The facility's policy related to falls was also requested but not received by the end of the survey. The deficiency centers on the facility's failure to ensure that care plan interventions to prevent falls were consistently implemented as documented.
Failure to Maintain Clean and Homelike Resident Environment
Penalty
Summary
Surveyors observed that a resident's room was not maintained in a clean and homelike condition as required. During an unannounced visit, the resident was found unresponsive to attempts at arousal, and the room contained unidentifiable brown stains on both the fitted and flat sheets where the resident was lying. The floor was sticky, the door had dried liquid stains, and the baseboards were coated with an unknown caked-on substance. Additionally, the resident's bathroom had feces present on the toilet seat. These observations were confirmed during a follow-up visit with the Director of Nursing, who acknowledged the need for cleaning. A review of the facility's cleaning procedures indicated that resident rooms are to be cleaned daily, including disinfecting sinks and toilets, mopping floors, and spot washing walls and doors when soiled. The resident involved had a history of Schizoaffective Disorder, muscle weakness, hypertension, and severe cognitive impairment, but was independent with transfers and bed mobility. Despite these protocols and the resident's needs, the room was not maintained according to the facility's standards at the time of the survey.
Privacy Violation Due to Improper Camera Placement
Penalty
Summary
The facility failed to maintain privacy for a resident, identified as R704, due to the improper placement of electronic monitoring devices in the resident's room. Observations revealed that two cameras were positioned in a manner that allowed them to face the room's entry door, potentially infringing on the privacy of other residents and staff in the hallway. The cameras were connected to the resident's mother's phone, allowing her to monitor the room in real-time and hear conversations. The Assistant Nursing Home Administrator confirmed that the cameras were incorrectly positioned and should have been facing only the resident. R704 was a resident with a severely impaired cognitive condition, non-verbal, and dependent on staff for all mobility and activities of daily living. The Director of Nursing contacted R704's mother to address the camera placement issue, explaining that the current positioning could violate the privacy of others. However, R704's mother insisted on her right to place the cameras as she wished, leading to a conflict between respecting the resident's family's wishes and maintaining the privacy and dignity of other residents.
Failure to Prevent Resident Abuse by Staff
Penalty
Summary
The facility failed to prevent verbal and physical abuse of a resident, identified as R801, by a staff member. On the midnight shift of 10/13/2024, LPN C was observed by Nurse D and CNA E yelling profanities at R801, who was trying to sleep on a couch in the dayroom. When R801 refused to get up, LPN C continued to yell and then physically lifted the couch, causing R801 to roll onto the floor. This incident was reported to the Assistant Director of Nursing by the observing staff members. R801, who was admitted with diagnoses including the presence of a right artificial joint and depression, required staff assistance with bed mobility and transfers. The resident was unable to complete a mental status assessment, indicating significant cognitive impairment. A family member, who is also the guardian, was not informed that a staff member was involved in the fall. The facility's abuse policy clearly states that residents have the right to be free from all forms of abuse, which was violated in this incident.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to report an abuse allegation in a timely manner involving a resident, identified as R801. The incident occurred during the midnight shift when an LPN was observed yelling profanities at R801 for trying to sleep on the couch in the dayroom. When the resident refused to get up, the LPN continued to yell and then physically lifted the couch, causing the resident to roll onto the floor. This incident was witnessed by a nurse and a CNA, who reported it to the Assistant Director of Nursing (ADON) the following morning. Despite the incident occurring on 10/12/2024, it was not reported to the State Agency (SA) until 10/14/2024. The delay in reporting was acknowledged by the ADON, who stated that the incident should have been reported immediately. The staff involved were subsequently educated on the proper procedures for reporting abuse allegations. The failure to report the incident promptly constituted a deficiency in the facility's compliance with regulations regarding the timely reporting of abuse allegations.
Deficiencies in Kitchen Sanitation and Food Storage
Penalty
Summary
The facility failed to maintain proper sanitation and food safety standards in the kitchen and resident food storage areas. During an initial tour of the kitchen, it was observed that two red sanitizer buckets with wiping cloths did not contain an effective sanitizer solution, as confirmed by a test strip that failed to change color. Additionally, stacks of metal pans were found with visible water droplets, indicating they were not properly dried before stacking, which is against the 2017 FDA Food Code requirements for air drying utensils. Further inspection of the resident refrigerators revealed multiple undated food containers and expired food items, such as a bag of cut watermelon dated over a week prior and several black, mushy bananas. The facility's policy requires that foods brought in from outside be stored in sealable containers, labeled, and dated, with refrigerated items discarded after 48 hours. These observations indicate a failure to adhere to the facility's food safety policies, potentially affecting all residents consuming food from the kitchen.
Deficiencies in Personal Care and ADLs for Residents
Penalty
Summary
The facility failed to provide adequate personal care for three residents, resulting in deficiencies in activities of daily living (ADLs). Resident R129, who has a diagnosis of Parkinsonism and requires assistance with ADLs, reported not receiving a shower for four weeks and had unwashed hair with white flakes. Despite being scheduled for showers twice a week, records showed R129 only received bed baths and one refusal. The resident's fingernails were also observed to be long and dirty. Staff cited a shortage of slings for mechanical lifts as a reason for not providing showers, although the resident did not refuse the care. Resident R61, diagnosed with hemiplegia and requiring assistance with ADLs, was observed with long chin hairs and reported not being shaved during bed baths. The resident expressed a preference for bed baths but did not prefer having long facial hair. The care plan indicated a need for substantial assistance with personal hygiene, which was not adequately provided. Resident R79, with diagnoses including Osteomyelitis and Chronic Obstructive Pulmonary Disease, reported excessively long toenails and could not recall seeing a podiatrist since admission. The Director of Nursing acknowledged the need for toenail trimming and stated that non-diabetic residents should have their toenails monitored and trimmed during ADL care. The facility's policy on ADLs and nail care emphasized regular grooming, which was not adhered to in these cases.
Failure to Document and Date PICC Line Dressings
Penalty
Summary
The facility failed to ensure proper documentation and care for PICC line dressings for two residents. For one resident, a rolled gauze dressing was observed on multiple occasions without a visible date or transparent dressing, and the insertion site was not visible. The LPN reported that the gauze dressing was used because the resident had previously pulled out the PICC line, and acknowledged that a transparent dressing should have been in place. The Unit Manager confirmed the absence of a date and transparent dressing. The resident's records showed no documentation of PICC line dressing changes, despite the administration of IV antibiotics being recorded. For the second resident, a transparent PICC line dressing was observed without a date. The Unit Manager confirmed the dressing should have been dated and noted that the resident's records lacked documentation of PICC line assessments or dressing changes since admission. An order for weekly dressing changes was entered by the infection control nurse on the day of observation. The Director of Nursing confirmed that PICC line dressings should be transparent, changed weekly, and dated, with assessments conducted when hanging each IV. The facility's policy outlined the procedure for dressing changes, which was not followed in these cases.
Deficiencies in Mechanical Lift Use and Smoking Policy Enforcement
Penalty
Summary
The facility failed to ensure the proper use and maintenance of a mechanical lift sling, leading to a fall and subsequent hospitalization of a resident. The resident, who had a history of cerebral infarction with left hemiplegia, muscle weakness, and anxiety disorder, fell from a mechanical lift due to a ripped sling. The incident occurred during a transfer from the bed to a lounger-chair, with only one CNA and a housekeeper present, contrary to the facility's policy requiring two trained staff members. The CNA did not inspect the sling before use, and the sling was found to be frayed and torn near the strap. Additionally, the facility failed to secure smoking and vape pens for residents, as observed with a resident who had a vape pen attached to a necklace and used it in their room, against the facility's smoking policy. The resident admitted to using the vape pen in their room due to delays in being assisted to the designated smoking area. The facility's policy prohibits smoking inside the building and requires smoking materials to be stored at the nursing station unless deemed safe by Resident Services. The facility's policies on safe lifting and smoking were not adhered to, resulting in unsafe conditions for residents. The mechanical lift policy mandates two staff members for transfers and regular equipment checks, while the smoking policy requires smoking materials to be kept at the nursing station and prohibits indoor smoking. These lapses in policy enforcement contributed to the deficiencies noted in the report.
Medication Storage Deficiency
Penalty
Summary
The facility failed to store medications securely and in accordance with professional principles for four residents. One resident was found with a white pill in a medication cup on their overbed table, and they were unsure how long it had been there. Another resident had an orange gel capsule in a medication cup on their window sill, which they did not take because they had a bowel movement and informed the nurse of their refusal. A third resident had a red inhaler on their overbed table and was unsure if it was supposed to be kept in their room. A fourth resident was found with a small plastic bag containing over 20 pills, which they stated they were not taking and did not need. This resident had a medical history of major depressive disorder, dementia with mood disturbance, and adjustment disorder with mixed anxiety and depressed mood. The Director of Nursing was shown the bag of pills and confirmed the facility's policy that medications should be taken with the nurse present, and any refused medications should be removed from the room. The facility's policy on medication storage emphasizes proper sanitation, temperature, light, ventilation, moisture control, segregation, and security.
Failure to Repair Malfunctioning Bed
Penalty
Summary
The facility failed to repair or replace a malfunctioning bed for a resident, identified as R136, who had been readmitted following a right above-knee amputation. The resident reported that the height adjustment of their bed had not worked since their admission, and despite informing multiple staff members, including maintenance and nursing staff, the issue was never addressed. During an observation, the resident demonstrated that while the head and foot adjustments worked, the height adjustment did not, producing a loud grinding noise instead. Interviews with facility staff, including a CNA and an LPN, revealed that they were aware of the bed's malfunction but had not reported it to maintenance. The Maintenance Director stated that they were unaware of the issue and that no work orders had been submitted regarding the bed. The Director of Nursing indicated that the expectation was for nursing staff to report such issues directly to maintenance or complete a work order. However, the facility administrator could not identify a policy addressing the reporting of malfunctioning equipment.
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The facility failed to implement its abuse prohibition policy and to ensure immediate reporting of suspected abuse, misappropriation, and injury of unknown origin. A resident with dementia and insomnia reported receiving diphenhydramine for several weeks from a nurse despite having only a one-time order, while an LPN and the supply clerk observed missing diphenhydramine stock and expressed concern it was being given without orders but did not report this to the administrator. Another cognitively intact resident with anxiety reported that two video games were missing and believed they were stolen, but the allegation was only shared with an unidentified staff member and was never reported to the administrator or state agency. In a separate case, a severely cognitively impaired resident was found with a large right forearm bruise of unknown origin that was first noted on a prior shift, not immediately reported to leadership, and subsequently reported to the state agency outside the required 2-hour timeframe.
The facility failed to timely and accurately report multiple allegations of abuse, neglect, and mistreatment to the State Agency. In one case, a resident with dementia and a history of falls sustained a hip fracture after being struck by a medication cart; a CNA who witnessed the event reported to administration that an LPN had pushed the cart recklessly, but her concerns were not investigated or reported as potential mistreatment. In another case, a resident with dementia and insomnia reported receiving diphenhydramine for sleep from a male nurse despite having only a one-time order, and an LPN reported concerns that a nurse was giving diphenhydramine without orders after finding opened bottles in the memory care medication room, yet this allegation was not reported. In a third case, a cognitively impaired resident alleged that a night-shift nurse grabbed and twisted her arm during incontinence care, with a bruise observed by an LPN; although the administrator was notified that morning, the incident was reported to the state more than two hours after the allegation and with an inaccurately late discovery time documented in the reporting system.
The deficiency involves the facility’s failure to thoroughly investigate two separate allegations of potential abuse and mistreatment. In one case, a resident with dementia and a known fall risk sustained a hip fracture after contact with a medication cart; documentation and multiple staff interviews conflicted about who witnessed the event and whether the cart struck the resident, yet the administrator relied primarily on an LPN’s account, conducted only a brief inquiry, and did not interview all identified witnesses. In the second case, a resident with vascular dementia reported receiving diphenhydramine for sleep from a male nurse despite having no order, and an LPN described finding opened and replaced bottles of diphenhydramine in the memory care medication room and statements suggesting it was being used to make residents sleep, but the facility’s investigation did not include interviewing this LPN and no incident report was submitted to the state agency.
A resident with severe cognitive impairment, bowel and bladder incontinence, and identified risks for falls and impaired skin integrity requested a brief change via call light. An activity assistant answered, turned off the call light, and left without providing care or notifying nursing staff. For over 30 minutes no staff returned, and when a CNA later entered only to deliver a meal tray, the resident was found with a soiled brief, visibly soiled linens, and dried stool on the buttocks, appearing distressed and repeatedly calling out about her diaper. The CNA, who had not been informed of the earlier request, then provided incontinence care. These events occurred despite facility policies requiring timely incontinence care and that call lights remain on until the resident’s request is met.
A resident with severe cognitive impairment, dementia, bipolar disorder, anxiety, PTSD, and profound hearing loss had care plans directing staff to use calm, individualized communication and behavioral approaches, allow time, avoid rushing, and re-approach when she became combative or refused care. Over the course of a night, multiple CNAs reported that she repeatedly refused incontinence care and became combative when approached, leading them to back off and re-approach later. Despite this history and the care plan guidance, an LPN and CNA later entered her room while she was half-asleep, pulled back her covers, and proceeded to change her wet brief as she tried to hit and kick; the LPN held her hands/arms while the CNA completed the change. The next day, staff observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted bruising on her forearm. These actions did not follow the resident’s behavior management and communication interventions and resulted in agitation, distress, resistance to care, and bruising.
A resident with severe cognitive impairment and a history of combative behavior repeatedly refused incontinence care and became physically aggressive when staff attempted to change a saturated brief. An LPN briefly held the resident’s arms to prevent being struck while a CNA completed the brief change, after which the resident allowed care. The next day, the resident reported that a male staff member had grabbed her arm, and an LPN observed bruising and fear but did not document these findings. Neither the pattern of care refusals and combativeness nor the subsequent bruising and related complaint were recorded in the EMR, despite facility policies requiring documentation of such behaviors and events, resulting in an incomplete and inaccurate medical record.
Two residents experienced development and worsening of coccyx and heel pressure ulcers due to the facility’s failure to implement and document ordered preventive and treatment interventions. One resident with severe cognitive impairment and mobility dependence had MASD, a non-blanchable heel, and orders for Triad paste and heel boots that were never documented as applied, no pressure-reducing surfaces or turning program on the MDS, and no skin notes for several days until an LPN discovered an undocumented coccyx ulcer under a foam dressing; later wound assessment showed an unstageable coccyx ulcer and a heel DTI acquired in the facility. Another resident admitted with a small coccyx open area and DVT had an order for barrier cream and a skin risk care plan, but there was no documentation of barrier cream use, the care plan was not updated when a stage 2 ulcer was identified, and multiple subsequent wound treatment orders (Triad paste, oil emulsion/alginate, Manuka Honey, Santyl, Dakin’s) were administered less frequently than prescribed, with delayed initial wound assessment and progression to a larger stage 3 coccyx ulcer requiring hospital transfer. The facility’s own wound and skin management policy requiring routine preventive care, daily CNA skin checks, and nurse skin assessments on bath days was not consistently followed as evidenced by missing documentation and treatment gaps.
Multiple cognitively impaired, high fall-risk residents experienced recurrent falls and serious injuries when staff failed to provide adequate supervision, safe transfers, and proper equipment use. One resident with dementia and prior hip fracture had several unwitnessed falls in the bedroom and near the nurses’ station, with investigations limited to adding non-skid strips, a fall mat, and low bed positioning rather than addressing recent illness, weakness, or sedation, and some interventions were not added to the care plan. Another resident with dementia, stroke, AFIB, and frequent falls, assessed by hospital PT as needing two-person assist, was care planned for only one-person contact guard and was repeatedly observed ambulating independently with an unsteady gait while staff did not assist or redirect; falls with head trauma and intracranial hemorrhage occurred, and staff held inconsistent understandings of required assistance and were not consistently interviewed after the events. Additional residents were pushed in wheelchairs without footrests, causing their feet to drag, despite available footrests and facility expectations, and one severely cognitively impaired resident’s fall investigation and care plan update regarding bed height were delayed and documented after discharge, with incomplete root-cause analysis.
A resident with morbid obesity, moderate cognitive impairment, and dependence on staff for toileting hygiene fell from a bariatric bed during incontinence care when staff did not ensure the resident was centered in the bed or adequately supervised while turning. The resident reported being instructed to cross one leg over the other and turn, then sliding off the bed when they flung their leg over, with only one staff member actively changing them. Facility records and CNA interviews showed the resident was close to the bed’s edge, staff positioning was inadequate, and required witness statements were not obtained in accordance with the facility’s fall reduction policy.
A resident with severe cognitive impairment and multiple medical conditions was transferred to a hospital in the afternoon for behavioral symptoms, as documented in nursing progress and discharge notes. However, the March MAR shows that an LPN documented administration of bedtime doses of magnesium oxide, metoprolol tartrate, and Seroquel later that evening, within the facility’s established bedtime medication window, even though the resident was no longer in the building. The DON confirmed the discrepancy between the transfer documentation and the recorded medication administration, indicating that medications were charted as given after the resident had been discharged.
Failure to Implement Abuse Policy and Immediately Report Suspected Abuse, Misappropriation, and Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff implemented the abuse prohibition policy and procedures, resulting in multiple incidents of potential abuse, neglect, and misappropriation not being reported immediately to the abuse coordinator/administrator. For one resident with vascular dementia and insomnia, the record showed only a single one-time order for diphenhydramine 25 mg (two tablets) by mouth, with no ongoing order. Despite this, the resident reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he did not want any more of the medication because he did not want his memory to worsen. Staff interviews further described concerns that diphenhydramine was being administered without a physician’s order and that these concerns were not reported as required. One LPN reported she was concerned another LPN was giving residents in the memory care unit diphenhydramine without orders, after a male resident repeatedly requested the medication and stated that “the other nurse” gave it to him. The same LPN found an opened bottle of diphenhydramine in the memory care medication room, noted that a significant amount was missing while no residents on that unit had orders for it, and reported that the other LPN had commented, “We’ll be ok tonight. I made sure everyone is going to sleep tonight.” She removed the open bottle, but a new bottle appeared the following night. She then instructed the supply clerk to stop stocking diphenhydramine in that medication room due to her concern that it was being given without orders. Neither the LPN nor the supply clerk reported these concerns to the administrator, despite the facility’s abuse policy requiring immediate reporting of suspected abuse or adverse events. The deficiency also includes failure to report an allegation of misappropriation of resident property and failure to immediately report an injury of unknown origin. A cognitively intact resident with generalized anxiety disorder reported that two video games valued at $160 were missing and believed they had been stolen. He stated he told an unidentified staff member, who responded that the games were not on his inventory list and would not be replaced. The resident did not report the issue to the administrator because he believed nothing could be done, and the administrator later confirmed that staff had never informed him of this allegation and that it was never reported to the state agency or investigated. In a separate incident, a resident with severe cognitive impairment, dementia, bipolar disorder, and generalized anxiety disorder was found to have a large bruise of unknown origin on the right forearm, extending from the wrist to the top of the forearm and covering most of the dorsal surface. The former DON learned of the bruise only after seeing it documented in CNA alert charting the day after it was first identified, and an incident report indicated the bruise was first noted on night shift the previous day. The CNA reported that she was told about the bruise by off‑going staff the following morning and then alerted the DON. The provider documented a new right dorsal forearm bruise of unknown mechanism, and the facility-reported incident was not submitted to the state agency within the required 2-hour timeframe, despite the facility’s policy requiring immediate reporting of suspected abuse, neglect, misappropriation, and adverse events.
Failure to Timely and Accurately Report Allegations of Abuse, Neglect, and Mistreatment
Penalty
Summary
The deficiency involves the facility’s failure to timely and accurately report allegations of abuse, neglect, or mistreatment to the State Agency for three residents. For one resident with dementia and a history of falls, staff documentation showed that a nurse pushing a medication cart collided with the resident, causing a fall and an acute right femoral neck fracture. A post-fall evaluation identified environmental factors, specifically that a cart pushed in the hall tripped the resident, and listed a CNA as a witness who later denied being present. Another CNA, who was not listed as a witness, reported she actually witnessed the event and described the nurse rapidly approaching from behind with the cart, appearing not to have control of it, and striking the back of the resident’s leg, causing the fall. This CNA stated she promptly called and texted the administrator and later spoke with the administrator and former DON, telling them she believed the resident was injured due to the nurse’s reckless actions, but she was never interviewed and her concerns were disregarded. The administrator reported he understood the event as the resident being startled and backing into the cart, did not view it as concerning, and did not report or further investigate the situation as potential mistreatment. No facility-reported incident related to this event was found in the State Agency database. The second component of the deficiency concerns an allegation that a nurse was giving diphenhydramine to residents on a memory care unit without physician orders. A resident with vascular dementia and insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognition. Review of physician orders showed only a one-time order for diphenhydramine for this resident, with no ongoing orders. Another LPN reported she was concerned that a male LPN was giving residents diphenhydramine without orders after a male resident repeatedly requested it and stated another nurse gave it to him, and after she found an opened bottle of diphenhydramine in the memory care medication room with no corresponding resident orders. She also reported that the male LPN had commented that he had made sure everyone would sleep that night. She removed the open bottle and later found a new bottle stocked, then asked the supply clerk to stop stocking it, but did not report her concerns to the administrator because she felt she lacked proof. The administrator later acknowledged awareness of a general concern about diphenhydramine in the medication room but denied being told that a specific nurse was allegedly using it to make residents sleep, and the State Agency database showed no facility-reported incident for this allegation at the time of review. The third component involves an allegation of staff-to-resident abuse that was not reported to the State Agency within the required two-hour timeframe and was inaccurately documented as to the time of discovery. A resident with severe cognitive impairment, multiple chronic conditions, and a history of falls and anxiety told her assigned LPN early in the morning that a night-shift nurse had grabbed and twisted her arm while a CNA provided incontinence care, despite her saying she was not wet. The LPN observed a bruise on the resident’s left arm, described the resident as frightened and not usually afraid, and reported that she notified the administrator immediately by phone and was instructed to monitor the bruise while the administrator would report the allegation and handle the investigation. An incident report documented the resident’s allegation, the observed bruise, and stated that nursing immediately reported to the administrator and that a report was filed with the state. However, the MI-FRI system showed the incident was submitted later that morning, more than two hours after the allegation was made, and recorded the discovery time as significantly later than when the LPN stated she first learned of it. The administrator confirmed he was notified of the allegation that morning, acknowledged that abuse allegations should be reported within two hours, and stated there were issues with the reporting system but could not provide a record of when he first attempted to submit the report.
Failure to Thoroughly Investigate Potential Abuse and Misuse of Medication
Penalty
Summary
The deficiency involves the facility’s failure to identify and thoroughly investigate potential abuse in two separate situations involving two residents. For the first resident, who had dementia with anxiety and was care planned as being at risk for fall-related injury due to poor safety awareness, the resident sustained a right femoral neck fracture after contact with a medication cart. Facility documentation in the fall report and post-fall evaluation stated that a nurse pushing a medication cart collided with the resident, that the fall was witnessed, and that the cart pushed in the hall tripped the resident. The post-fall evaluation listed a CNA as a staff/witness present and a laundry aide as the primary assistant interviewed for the three hours prior to the fall, and identified environmental factors as the root cause. However, interviews revealed discrepancies and incomplete investigation. The CNA listed as a witness reported she was not present at the time of the fall and only saw the resident later that evening, contradicting the post-fall documentation. The laundry aide reported she was in the hallway at the time of the fall, saw the resident walking next to a CNA, and observed the LPN, the medication cart, and the CNA all together when the resident fell, but stated she did not know if the cart hit the resident and that she was never interviewed by the administrator about what she saw. A former CNA reported she directly witnessed the fall, describing that she was pushing another resident in a wheelchair while the injured resident walked beside her, and that an LPN approached rapidly from behind with the medication cart, appeared not to have control of it, and that the cart struck the back of the resident’s leg, causing the fall. This CNA also reported she had told the administrator and DON by phone that she believed the resident was injured due to the LPN’s reckless actions, but that her concerns were disregarded and she was never interviewed. The LPN involved stated that both she and the resident were in motion and that the resident backed into the cart, causing loss of balance and a fall, and confirmed the resident’s hip fracture. The administrator’s written summary reflected only the LPN’s account, characterizing the event as an accident and documenting that the resident backed up and clipped the corner of the cart. In interview, the administrator described his investigation as brief, stated that when an LPN calls and tells him exactly what happened there was little need for further investigation, and could not confirm speaking to other witnesses such as the laundry aide. He acknowledged that the CNA had mentioned a concern that the nurse may not have accurately reported what happened but did not elaborate or explore whether any earlier interaction might have contributed to the incident. These actions and omissions demonstrate that the facility did not conduct a thorough investigation into a potential abuse or mistreatment situation involving a fall with major injury. The second situation involved an allegation of improper administration of diphenhydramine to residents without physician orders. One resident with vascular dementia, moderate cognitive impairment, and a history of insomnia reported that a male nurse had been giving him diphenhydramine for at least a few weeks to help him sleep, and that another nurse later told him the medication was not recommended for people with dementia because it could worsen cognitive skills. The resident stated he had used the medication nightly before admission but now did not want anything that could make his memory worse. A nurse practitioner confirmed that none of the residents on the memory care unit had orders for diphenhydramine and that its use in dementia patients increased fall risk and had a sedating effect. An LPN reported concerns that another LPN was giving residents diphenhydramine without physician orders. She stated that a male resident repeatedly requested the medication and told her that another nurse gave it to him, and that she found an opened bottle of diphenhydramine in the memory care medication room with a significant amount missing despite no residents having orders for it. She also reported that the other LPN told her he had made sure everyone was going to sleep that night, and that after she removed the open bottle, a new bottle appeared the following night. She did not report this to the administrator at the time because she felt she lacked proof. The administrator later stated he was aware of an allegation of misuse of diphenhydramine and that an investigation was underway, but the soft file showed only 9 of 27 licensed nurses had been interviewed and there was no record that this LPN, who had direct knowledge of the concern, was interviewed. The administrator stated that the LPN had expressed only general concerns about finding diphenhydramine in the medication room and denied that she had reported an allegation that another nurse was giving it to residents without orders to make them sleep. Review of the state agency’s facility-reported incidents database showed that no investigation related to the accusation of a nurse giving residents diphenhydramine without an order had been submitted. These facts show the facility did not fully identify, investigate, and report an allegation of potential abuse and misuse of medication as required by its abuse prohibition policy.
Failure to Provide Timely Incontinence Care and Proper Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and to appropriately respond to a resident’s call light request. The resident was a female with multiple diagnoses including heart failure, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss, and had a BIMS score of 5 indicating severe cognitive impairment. Her MDS indicated she was frequently incontinent of urine and always incontinent of bowel, and her care plans identified risks for falls and impaired skin integrity, with interventions to remind her to use the call light and to complete hygiene care expeditiously. On the survey date at 11:02 AM, the resident was observed in bed with her call light activated. An activity assistant responded, and the resident requested a brief change. The assistant turned off the call light without providing care and left to find nursing staff, but did not locate anyone or communicate the resident’s request. At 11:32 AM, the resident was still in bed and no staff had returned to provide the requested brief change, 30 minutes after the call light had been answered and deactivated. The activity assistant later confirmed she had not yet found staff or informed nursing of the resident’s need. At 11:44 AM, a CNA entered only to deliver the lunch tray and was not aware of the earlier request. At that time, the resident removed a soiled brief and threw it on the floor; she was incontinent of bowel, with visibly soiled linens and dried bowel movement on both buttocks that required additional soaking and washing to remove. The resident appeared distressed, moved frequently in bed, repeatedly said “diaper,” and stated that her “butt hurts,” and became agitated and aggressive during care. The interim DON stated that staff should leave the call light on if the need cannot be immediately addressed. Facility policies on routine resident care and call lights required timely incontinence care and that call lights remain on until the resident’s request is met, which was not followed in this incident.
Failure to Honor Dementia Resident’s Refusal and Use Individualized Behavior Approaches During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to provide care that maintained the highest practicable physical and mental well-being for a resident with dementia, cognitive deficits, and behavioral symptoms. The resident was an elderly female with multiple diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. Her MDS showed a BIMS score of 5, indicating severe cognitive impairment. Her care plans identified impaired communication related to hearing loss, impaired cognition related to dementia, and potential for mood fluctuations related to bipolar disorder, major depression, anxiety, and dementia. The care plans directed staff to use specific communication techniques, allow adequate time to respond, avoid rushing, use simple words and cues, limit choices, use task segmentation, and approach her in a calm, quiet manner with appropriate body language. In the period leading up to the incident, multiple CNAs reported that the resident had a history of being combative and resistant to incontinence care, sometimes attempting to hit, kick, or swing at staff when approached. Staff who were familiar with her reported that when she refused care or became combative, they would give her space, re-approach later, or have a different caregiver attempt care, and that her reactions were influenced by how staff approached her. On the evening and night in question, CNAs reported that the resident repeatedly refused incontinence care and became combative when they attempted to change her brief. One CNA stated that she informed the oncoming shift CNA and an LPN that the resident had refused care and that her brief had not been changed during the evening due to these refusals. That CNA reported that the LPN stated the resident had to be changed regardless of whether she wanted to be. Later during the night shift, an LPN and a CNA entered the resident’s room around 3:00 AM to attempt incontinence care. The LPN reported that the resident was “half-asleep” when they began to change her wet brief. According to the CNA, when the LPN pulled back the covers, the resident began trying to hit and kick. The LPN held the resident’s hands or arms to prevent being struck while the CNA changed the resident’s wet brief. The CNA reported that after a few moments the resident stopped resisting and allowed the care to be completed. Subsequently, the day-shift LPN observed that the resident was frightened, reported that a male staff member had grabbed her arm, and noted a bruise on the resident’s left arm. Another CNA later observed oval-shaped bruising on one of the resident’s forearms. Staff interviews and the facility’s behavior management policy emphasized that behaviors should be recognized as communication, that causes and triggers such as fatigue and sensory deficits should be considered, and that individualized, non-pharmacological interventions and behavior management strategies should be used. Despite existing care plan interventions and policy expectations, staff proceeded with incontinence care while the resident was half-asleep and actively resisting, and the LPN physically held her arms, leading to the resident’s agitation, distress, resistance to care, and bruising. The facility’s behavior management policy stated that behaviors are a form of communication and that staff should attempt to identify causes and triggers, including fatigue, lack of sleep, and sensory deficits such as hearing loss. The policy also required the IDT to implement care plans with specific non-pharmacological interventions and behavior management strategies for residents with dementia or mental illness. In this case, the resident’s known history of combative behavior, her severe cognitive impairment, profound hearing loss, and the time of night were all relevant factors. Nonetheless, staff actions during the incident did not align with the care plan directives to avoid rushing, to use calm approaches, and to re-approach later when the resident was resistant. Instead, the decision to proceed with incontinence care while the resident was half-asleep and combative, and to physically hold her arms, directly contributed to the resident’s distress and the observed bruising on her arm. The deficiency is further supported by staff accounts that the resident’s behaviors could often be managed by giving her space, re-approaching at a later time, or using different caregivers, and that she was not good at communicating her needs vocally and had impaired hearing. The day-shift LPN described the resident as usually not afraid, but on this occasion she was frightened and requested that the LPN not allow the male nurse into her room, stating he had grabbed her arm. The assistant director of nursing and social worker both acknowledged the resident’s history of combative behaviors and resistance to care, and that these behaviors were related to her mental health diagnoses and dementia. The combination of proceeding with care despite active resistance, failing to fully utilize the individualized behavioral and communication strategies in the care plan, and physically restraining the resident’s arms during care constituted the failure to provide appropriate treatment and services to a resident with dementia, resulting in agitation, distress, resistance to care, and bruising.
Failure to Document Resident Care Refusals, Combative Behaviors, and Resulting Bruising
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for one resident with significant cognitive and behavioral issues. The resident was an elderly female with diagnoses including heart failure, insomnia, PTSD, bipolar disorder, dementia, anxiety, obstructive lung disease, arthritis, a history of falls, and hearing loss. An MDS assessment showed a BIMS score of 5/15, indicating severe cognitive impairment. On the night in question, a CNA reported that the resident repeatedly refused incontinence care and became combative when staff attempted to change her brief, which had not been changed since around dinner time the prior evening due to her refusals and combative behavior. During the early morning hours, the CNA and an LPN entered the resident’s room to again attempt incontinence care. According to the CNA, when the LPN pulled back the covers, the resident tried to hit and kick. The LPN held the resident’s hands so staff would not be struck while the CNA changed the resident’s wet brief. After a short time, the resident stopped resisting and allowed care to be completed. The LPN later confirmed that he had been notified by CNAs that the resident was combative and refusing care, that he went to assist with incontinence care, that the resident was “half-asleep” when they began, and that he held her hands/arms briefly to prevent being hit. He acknowledged that he did not document the pattern of incontinence care refusals or the combative behaviors in the electronic medical record. The following day, the resident told her assigned day-shift LPN not to let the male LPN into her room because he had grabbed her arm. The day-shift LPN observed a bruise on the resident’s left arm and described the resident as frightened and not usually afraid. She reported that the administrator directed her to monitor the bruise, but she did not document the bruise or her observations because she was unsure what the administrator wanted her to do. The unit manager, ADON, and social worker all reported that the resident had a history of combative behaviors and resistance to care, and they each stated that refusals of care and combative behaviors should be documented by CNAs and nursing staff in the electronic medical record. Review of the resident’s progress notes showed no documentation of care refusals or combativeness on the relevant dates, despite facility policies requiring complete documentation of behaviors, refusals, and deviations from standard care. This lack of documentation resulted in an incomplete and inaccurate medical record for the resident. Facility policies on Behavior Management and Documentation Expectations required staff to document behaviors, including new and escalating behaviors, and all pertinent information related to events, resident condition, and deviations from standard treatment in the medical record. The policies specified that staff should use the electronic medical record system to record behaviors and the effectiveness of interventions, and that all facts and pertinent information related to events and resident condition must be documented. In this case, the repeated refusals of incontinence care, the resident’s combative behavior, the use of physical holding during care, and the subsequent observation of bruising and fear were not documented in the resident’s record, contrary to these policies. This omission formed the basis of the cited deficiency for failing to ensure a complete and accurate medical record.
Failure to Implement Ordered Pressure Ulcer Prevention and Treatment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement ordered pressure ulcer prevention and treatment interventions, resulting in the development and worsening of pressure ulcers in two residents. One resident was re-admitted with diagnoses including cervical spine surgery, diabetes, and metabolic encephalopathy. An admission skin assessment documented no ulcers or skin treatments, but a subsequent assessment identified MASD in the groin and scrotum, a non-blanchable and discolored left heel, and an order for protective heel boots and Triad paste to the coccyx. There was no documentation that the Triad paste or heel boots were ever applied. The resident’s MDS later showed severe cognitive impairment, extensive assistance needs for mobility, and one unstageable DTI, with no pressure-reducing bed or chair and no turning/repositioning program documented. A care plan for risk of skin breakdown was initiated with interventions such as floating heels, pressure-reducing mattress and cushion, and assistance with turning and repositioning, but there were no progress notes or skin assessments for this resident’s skin from mid-December until late December. On a later date, an LPN discovered a foam dressing on the resident’s coccyx during incontinence care and, upon removal, observed an area with eschar and additional open areas along the bilateral buttock region at the tailbone. There were no measurements or detailed descriptions of these wounds at that time, and a treatment order for Manuka Honey to the coccyx was documented as being administered only twice despite being ordered three times weekly. The LPN who found the dressing stated they had not known of any wound prior to that and confirmed there were no prior notes or treatment orders for the coccyx. The DON confirmed there were no skin assessments or treatment orders for the coccyx until that date and that this lack of documentation was not consistent with facility protocol. Another LPN later admitted to having applied the foam patch to the coccyx two days earlier after noticing an ulcer, but stated they became too busy and failed to chart the finding or notify the physician, acknowledging this was not in line with protocol. An initial wound care note several days later documented an unstageable coccyx pressure ulcer with extensive eschar and a DTI on the left heel, and an RN confirmed these pressure ulcers were acquired in the facility and that there had been a delay in prevention and treatment. The second resident admitted with multiple diagnoses including osteoarthritis of the left knee and DVT. Shortly after admission, an RN documented a dime-sized open area on the coccyx, and an order was written for barrier cream as needed after incontinence care, along with a care plan for risk of skin breakdown that included frequent turning and repositioning, use of barrier cream, and pressure-reducing surfaces. There was no documentation that the barrier cream was applied to the coccyx wound. The resident’s MDS later indicated intact cognition, extensive assistance needs for mobility, and one stage 2 pressure ulcer, but the care plan was not revised to reflect actual skin breakdown. No additional progress notes or assessments for the coccyx ulcer were documented until nine days after admission, when a specific Triad paste treatment was ordered. MAR review showed that this treatment was given only three times instead of the prescribed six times over three days, and the order was then discontinued. Subsequent treatment orders for this resident’s coccyx ulcer were repeatedly changed, including orders for oil emulsion and alginate dressings three times weekly and Triad paste to the periwound area, but MARs showed that these treatments were administered less frequently than ordered before being discontinued. An initial wound care note two weeks after admission documented a stage 3 coccyx wound with necrotic tissue and specific measurements. Later, a Manuka Honey and alginate regimen three times weekly was ordered, but again MARs showed missed treatments. A subsequent daily Santyl and alginate regimen was documented as administered on most but not all ordered days, with no PRN treatments documented, and then changed to a Dakin’s solution plus Santyl and alginate regimen. A later wound care note documented a larger stage 3 coccyx pressure ulcer with increased dimensions and depth, and the resident was transferred to the hospital for worsening of the pressure ulcer. An RN acknowledged that the resident admitted with a small open area on the coccyx that progressed to a larger stage 3 ulcer, confirmed that no skin treatments were documented until nine days after admission, and noted gaps in the MAR where ordered treatments were not administered. The facility’s Wound and Skin Management Policy required prevention of avoidable pressure ulcers, necessary treatment and services, routine preventive care including turning, pressure reduction devices, good skin care, and daily CNA skin assessments with prompt reporting of new breakdowns, as well as nurse validation and skin assessment on bath/shower days, which were not consistently carried out as documented in these cases.
Failure to Prevent Falls, Ensure Safe Transfers, and Conduct Adequate Fall Investigations
Penalty
Summary
The deficiency involves the facility’s failure to prevent avoidable falls, to provide adequate supervision, and to conduct thorough root-cause analyses for multiple residents with known fall risks and cognitive impairment. One resident with vascular dementia, severe cognitive impairment, unsteadiness, and a history of hip fracture experienced several falls in his room and near the nurses’ station. Documentation showed he was found face down with his shoulder pinned under a roommate’s bed after returning from a cystoscopy with a Foley catheter and recent gross bleeding, and later was admitted to the hospital for sepsis, UTI, metabolic encephalopathy, rhabdomyolysis, and COVID. Subsequent falls included being found on the floor in front of his bed with shoes on and later on the floor next to a roommate’s bed with a laceration and a right hip fracture. The facility’s fall investigations repeatedly cited environmental changes such as adding non-skid strips, a fall mat, and low bed position, but did not address underlying causes such as recent illness, weakness, sedation, or his pattern of recurrent falls in the bedroom. The DON acknowledged that increased supervision or more frequent checks would have been more appropriate, and non-skid strips were not consistently added to the care plan. Another resident with dementia, frequent falls, stroke, syncope, AFIB, and severe cognitive impairment had multiple falls and head injuries, including a posterior head hematoma and later a subdural and subarachnoid hemorrhage. On admission, the baseline care plan required a two-person pivot transfer, and hospital PT had assessed the resident as needing maximum two-person assist for transfers and ambulation. However, the care plan was later documented as requiring only contact guard assist by one person for ambulation without devices, and staff interviews revealed inconsistent understanding of what “contact guard” meant, with some staff treating it as stand-by assist with no hands-on contact. The resident was observed independently ambulating in the room and hall with very unsteady gait, repeatedly pacing and grabbing side rails and carts, while staff did not attempt to assist or redirect. Falls occurred during care by a private home health aide and later when the resident independently transferred and fell in the doorway, with staff reporting that the resident frequently ambulated independently when staff were occupied. The facility’s interventions focused on adding a floor mat and low bed, while the root-cause documentation cited poor safety awareness, restlessness, and misunderstanding of limitations, and there was a delay in IDT follow-up documentation and incomplete provision of witness statements. Additional deficiencies involved unsafe wheelchair use and incomplete fall investigation for other residents. One cognitively impaired resident who required partial to moderate assistance for ADLs and used a walker was observed being pushed in a wheelchair without footrests, with the CNA stating there were not enough footrests, despite the regional PT showing multiple totes full of footrests and stating CNAs could obtain them without therapy assistance; the DON confirmed the expectation that footrests be used when pushing residents. Another resident with dementia, repeated falls, and dependence for ADLs was also pushed in a wheelchair with feet dragging on the floor and no footrests, with the CNA again citing a shortage of footrests. A further resident with severe cognitive impairment and multiple medical conditions had a fall where she was found on the floor next to the bed with the bed not in the lowest position and the call light within reach but not used; the root cause was documented as possibly rolling out of bed. A later fall for this resident resulted in significant facial and head injuries, but the investigation note and care plan intervention of keeping the bed in the lowest position were created after the resident had already been discharged to the hospital, and the facility’s investigation documentation lacked timely, complete root-cause analysis and contemporaneous care plan updates. Across these cases, the survey findings describe repeated failures to align care and supervision with residents’ assessed needs and documented care plans, inconsistent or delayed fall investigations, and reliance on protective environmental measures that did not address the actual causes of recurrent falls. Residents with high fall risk, severe cognitive impairment, and documented need for significant assistance were allowed to ambulate independently or be transported unsafely in wheelchairs without footrests, and staff interviews revealed confusion about required levels of assistance and lack of follow-up questioning of key witnesses after serious falls. The facility did not consistently incorporate identified risks such as recent illness, sedation, restlessness, and poor safety awareness into individualized, effective fall-prevention interventions or into the care plans in a timely manner.
Failure to Safely Position and Supervise Resident During Incontinence Care Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to provide safe positioning assistance and adequate supervision during incontinence care, resulting in a fall from bed for resident R103. R103, who resides in a bariatric bed and reported being unable to walk or stand but able to move about in bed, stated that they fell out of bed a few days prior while staff were providing incontinence care one side at a time. R103 described being instructed to cross one leg over the other and turn, and reported that they did not realize how close they were to the edge of the bed; when they flung their leg over, they slid off the bed onto the floor. R103 reported that only one staff member was changing them at the time, and that a mechanical lift plus three staff were needed to return them to bed. Record review showed that R103 had diagnoses including acute respiratory failure with hypoxia, morbid obesity, and age-related physical debility, with a Minimum Data Set documenting moderate cognitive impairment and dependence on staff for toileting hygiene. A nurse progress note documented that on the morning of the fall, the CNA reported the resident had rolled out of bed during care, and the nurse found the resident on the floor on their left side with the bed in a low position. The fall incident report similarly recorded that the resident rolled out of bed during care and that, per CNA F’s statement, the resident was asked to turn onto their side and continued rolling, inadvertently rolling out of bed. The root cause analysis documented that the interdisciplinary team determined the resident was not positioned in the center of the bed when staff entered to complete care rounds, and that both CNAs were attempting to reposition the resident to the center of the bed when the resident rolled out of bed. Interviews with CNAs involved revealed inconsistencies and gaps in supervision and positioning practices. CNA G stated that despite the resident’s size, the resident was very mobile and considered a two-person assist for safety, and reported that they were in the process of changing the resident when the fall occurred. CNA G initially claimed that both CNAs were on opposite sides of the bed such that there was no room for the resident to fall, but later said they did not know where CNA F was positioned and then stated they did not remember. CNA F reported that the resident was somewhat close to the edge of the bed, not centered, and that during turning for incontinence care the resident threw their top leg over the other and fell off the bed on the opposite side, while CNA G was at the foot of the bed rather than at the center on the opposite side. The Director of Nursing confirmed that witness statements from the CNAs were not obtained as required by the facility’s fall reduction policy and acknowledged that if staff had been positioned close to the bed and used a draw sheet to move the resident to the middle of the bed prior to care, the fall could have been prevented.
Inaccurate MAR Documentation for Medications After Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate medical record regarding medication administration for a resident with severe cognitive impairment and multiple diagnoses, including acute respiratory failure with hypoxia, hypertension, and bipolar disorder. The resident was admitted in late September and discharged in early March. On the day of discharge, nursing documentation shows that the resident was transferred to a local hospital in the mid-afternoon due to behavioral symptoms, with a discharge note at 3:33 PM and a nursing progress note at 3:38 PM confirming that EMTs responded to a 911 call, the resident’s guardian consented to transfer, and the physician and DON were notified. The resident was transported to the hospital via stretcher and was no longer in the facility after that time. Despite the resident’s transfer out of the building that afternoon, the March Medication Administration Record (MAR) documented that bedtime doses of magnesium oxide 400 mg BID for hypomagnesemia, metoprolol tartrate 100 mg BID for tachycardia, and Seroquel 25 mg BID for bipolar disorder were administered by an LPN at bedtime that same day. The LPN assigned to the second shift stated that bedtime medications were to be given at 9 PM, with a one-hour window before or after, but could not recall whether the resident was in the building around that time. The DON confirmed that the facility’s bedtime medication administration window was between 7 PM and 10 PM and, upon reviewing the MAR and progress notes, questioned how the medications could have been administered when the resident had already been transferred to the hospital, indicating that someone documented administration of medications after the resident had been discharged from the facility.
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